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(r WELL PERMIT APPLICATION FORM L <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />O � (209) 468-3449 Lie <br />l � 6c�eoG <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application lance w th San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joa quip Pounty Environmental Health Department. <br />WELL Location. - ly w mss Street /N2 / c sTc-t�TUr.y Zip ' Assessor's <br />v° ��� i Parcel# //7 - bg - 27 <br />PROPERTY v <br />OwnertueTe,t Gln.ijfe���Glt Address 0'VY /V 131K4144! City Zip `CZo5�1Phone# Z01- 9f-3 - yL90 <br />05 r" f4 C5-7 - <br />C-57 Contractor ( L IL /4'!!t Address �9320plee- City GoreiZPAL Zip 1r7Y2-Lic# 71757o Phone# 9/.- CTB- )] 61Y <br />Consultant / Sub /� /t <br />Contractor /g�Qts n✓��s��ddress 77 .3-?ly 3 ✓� City /hoenfb Lic# <br />2 8S'oa3 <br />GIS Coordinates: X 121 I( -c 16.67 Y_ )wnship ZN <br />'S-7 578 87 r <br />WORK TO BE PERFORMED: <br />,RNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />WELL# Mk,/ -/1 <br />'Other: <br />COMMENTS: <br />Grout Specifications: <br />Phone# !02'72$-0707 <br />Range 2aV 6E Section '3C� <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />�i <br />MONITORING RHOLLOW STEM DIA. OF BOREHOLE /10 �4' MULTIPLE CASINGS? YES [] NO WELL CASING DIA: 2 - <br />EXTRACTION <br />EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />CASING THICKNESS �•/f`� TYPE OF CASING: [] STEEL APVC [] OTHER: \` <br />0 VAPOR <br />[] MUD ROTARY <br />DEPTH OF GROUT SEAL 61!9 3L' <br />TREMIE TYPE TO BE USED: J AUGERS 0 HOSE <br />[] AIR SPARGE <br />[] PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes )INo (NOTE: <br />MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING <br />[] HAND AUGER <br />GROUT SPECIFICATIONS: Ne4,%C'e <br />—Tyle -1C <br />0 OTHER: <br />_0 OTHER <br />APPROX. BORING DEPTH 1S57 <br />BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? <br />( if YES, list specifications here): <br />'COMMENTS: <br />/�� � � <br />�Lu)r�rtiT� S2.cP 9e�eeti- <br />SQ 14ek- CQ5;✓VL <br />& 6&4±%po <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules <br />�and Regulations, and all applicable California <br />�State Laws. p <br />Signed x /`� :' *-+�f� Title/Company Ti4?,t '�' ► 1 c 14 -e -s 6✓dht � <br />Print Name ��C' /Qvt 1� Date Z// 5-14 2- <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: P <br />Application Accepted By <br />Grout Inspection By <br />Date <br />Destruction Inspection B <br />COMMENTS / CONDITIO <br />DEPARTMENTUSE ONLY <br />Date <br />Date <br />Gales— /- 2-3 -b 7 -- <br />ate Issued T—b� Area <br />Final Inspection By <br />IJ <br />ACCOUNTING ONLY: AID# rnr+4 <br />PE CODES <br />FEE I�N`FO/ <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PE RVICE/REQUEST # <br />VOICE <br />C-57 ✓ WC= WAIVER_ C-57 Letter of Authorization to sign permit oc_ 1/25/02 <br />